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1 GAO United States Government Accountability Office Report to the Ranking Member, Committee on Veterans Affairs, House of Representatives October 2011 VA MENTAL HEALTH Number of Veterans Receiving Care, Barriers Faced, and Efforts to Increase Access GAO-12-12

2 October 2011 VA MENTAL HEALTH Number of Veterans Receiving Care, Barriers Faced, and Efforts to Increase Access Highlights of GAO-12-12, a report to the Ranking Member, Committee on Veterans Affairs, House of Representatives Why GAO Did This Study In fiscal year 2010, the Department of Veterans Affairs (VA) provided health care to about 5.2 million veterans. Recent legislation has increased many Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) veterans priority for accessing VA s health care, and concerns have been raised about the extent to which VA is providing mental health care to eligible veterans of all eras. There also are concerns that barriers may hinder some veterans from accessing needed mental health care. GAO was asked to provide information on veterans who receive mental health care from VA. In this report, GAO provides information on (1) how many veterans received mental health care from VA from fiscal years 2006 through 2010, (2) key barriers that may hinder veterans from accessing mental health care from VA, and (3) VA efforts to increase veterans access to VA mental health care. GAO obtained data from VA s Northeast Program Evaluation Center (NEPEC) on the number of veterans who received mental health care from VA. The number of veterans represents a unique count of veterans; veterans were counted only once, even if they received care multiple times during a fiscal year or across the 5-year period. GAO also reviewed literature published from 2006 to 2011, reviewed VA documents, and interviewed officials from VA and veterans service organizations (VSO). View GAO or key components. For more information, contact Debra A. Draper at (202) or What GAO Found Over the 5-year period from fiscal years 2006 through 2010, about 2.1 million unique veterans received mental health care from VA. (See figure.) Each year the number of veterans receiving mental health care increased, from about 900,000 in fiscal year 2006 to about 1.2 million in fiscal year OEF/OIF veterans accounted for an increasing proportion of veterans receiving care during this period. Number of Veterans Who Received Mental Health Care from VA, Fiscal Years 2006 through 2010 Veterans 2,100,000 1,800,000 1,500,000 1,200, , , , , , OEF/OIF Source: GAO analysis of NEPEC data. 1,027, ,118, All other veterans 1,203, ,060,211 Number of unique veterans, fiscal years 2006 through 2010 The key barriers identified from the literature that may hinder veterans from accessing mental health care from VA, which were corroborated through interviews, are stigma, lack of understanding or awareness of mental health care, logistical challenges to accessing mental health care, and concerns about VA s care, such as concerns that VA s services are primarily for older veterans. Many of these barriers are not necessarily unique to veterans accessing mental health care from VA, but may affect anyone accessing mental health care from any provider. Veterans may be affected by barriers differently based on demographic factors, such as age and gender. For example, younger OEF/OIF veterans and female veterans may perceive that VA s services are primarily for someone else, such as older veterans or male veterans. VA has implemented several efforts to increase veterans access to mental health care, including integrating mental health care into primary care. VA also has implemented efforts to educate veterans, their families, health care providers, and other community stakeholders about mental health conditions and VA s mental health care. According to VA officials, these efforts help get veterans into care by reducing, and in some cases eliminating, the barriers that may hinder them from accessing care. GAO provided a draft of this report to VA for comment. In its response, VA provided technical comments, which were incorporated as appropriate. United States Government Accountability Office

3 Contents Letter 1 Background 4 More Than 2 Million Unique Veterans Received Mental Health Care from VA over the 5-Year Period from Fiscal Years 2006 through Stigma, Lack of Understanding of Mental Health, Logistical Challenges, and Concerns about VA May Hinder Veterans from Accessing Care 11 VA Has Implemented Several Efforts to Increase Veterans Access to Mental Health Care 15 Agency Comments 20 Appendix I Scope and Methodology 21 Appendix II Number of Veterans Receiving Mental Health Care from VA by Setting and Era, Fiscal Years 2006 through Appendix III Number of Veterans Receiving Care from VA by Gender and Era, Fiscal Years 2006 through Appendix IV Comments from the Department of Veterans Affairs 26 Appendix V GAO Contact and Staff Acknowledgments 27 Tables Table 1: Veteran Eras of Military Service 5 Table 2: Five Most Common Diagnostic Categories for Veterans Receiving Mental Health Care from VA, Fiscal Year Table 3: Key Barriers That May Hinder Veterans from Accessing Mental Health Care from VA 11 Table 4: Examples of VA Efforts to Educate Specific Groups of Veterans about VA Mental Health Care 18 Page i

4 Figures Figure 1: Number of Veterans Who Received Mental Health Care from VA, Fiscal Years 2006 through Figure 2: Percentage of Veterans Receiving Mental Health Care from VA as a Percentage of the Total Number of Veterans Receiving Any Health Care from VA over the 5-Year Period from Fiscal Years 2006 through Abbreviations NEPEC OEF OIF PTSD VA VHA VSO Northeast Program Evaluation Center Operation Enduring Freedom Operation Iraqi Freedom post-traumatic stress disorder Department of Veterans Affairs Veterans Health Administration veterans service organization This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Page ii

5 United States Government Accountability Office Washington, DC October 14, 2011 The Honorable Bob Filner Ranking Member Committee on Veterans Affairs House of Representatives Dear Mr. Filner: In fiscal year 2010, the Department of Veterans Affairs (VA), which operates one of the largest health care delivery systems in the nation, provided health care to about 5.2 million veterans. VA provides care to eligible veterans from all eras of service, 1 including World War II, Korea, Vietnam, Gulf War, and most recently, military operations in Afghanistan and Iraq Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), respectively. 2 Recent legislation has increased many OEF/OIF veterans priority for accessing VA s health care. 3 Given the increased focus on OEF/OIF veterans, concerns have been raised by some, including veterans service organizations (VSO), about the extent to which VA is providing mental health care to eligible veterans of all eras. We have previously reported that VA has experienced an increased demand for its mental health care including care for 1 Veterans who served in active military and who were discharged or released under conditions other than dishonorable are generally eligible for VA health care. Reservists and National Guard members may also be eligible for VA health care if they were called to active duty by a federal order and completed the full period for which they were called. Veterans can also receive health care funded by sources other than VA, including private insurance, Medicare, and Medicaid. In general, veterans must enroll in VA health care to receive VA s medical benefits package a set of services that includes a full range of hospital and outpatient services, prescription drugs, and noninstitutional long-term care services. 2 Military operations in Afghanistan occurring after September 2010 are referred to as Operation New Dawn. For the purposes of this report, we refer to all veterans participating in military operations in Afghanistan as OEF veterans. 3 See 38 U.S.C. 1710(a), 38 C.F.R , (2009). Any veteran who has served in a combat theater after November 11, 1998, including OEF/OIF veterans, and who was discharged or released from active service on or after January 28, 2003, has up to 5 years from the date of the veteran s most recent discharge or release from active duty service to enroll in VA s health care system and receive VA health care services. See 38 U.S.C. 1710(e)(1)(D), (e)(3). Page 1

6 conditions such as post-traumatic stress disorder (PTSD), depression, and substance abuse. 4 Additionally, there are concerns that barriers such as distance from a VA treatment facility or stigma associated with mental health care may hinder some veterans from accessing needed mental health care. When veterans do not receive the mental health care they need, wide-ranging and negative implications for their physical, work, family, and social functioning can result. For example, mental health conditions can lead to increased risks of unemployment, homelessness, and suicide. You expressed interest in obtaining information on veterans who receive mental health care from VA. In this report, we provide information on (1) how many veterans received mental health care from VA from fiscal years 2006 through 2010, (2) key barriers that may hinder veterans from accessing mental health care from VA, and (3) efforts VA has implemented to increase veterans access to VA mental health care. To perform our work, we obtained data from VA s Northeast Program Evaluation Center (NEPEC) 5 on the number of veterans who received mental health care from VA from fiscal years 2006 through For the purposes of this report, we defined mental health care as the care provided to veterans with mental health conditions. A veteran was counted as having a mental health condition if, at any point in the fiscal year, his or her medical record indicated at least two outpatient encounters with any mental health diagnosis (with at least one encounter having a primary mental health diagnosis) or an inpatient stay in which the veteran had any mental health diagnosis. 6 Additionally, the number of veterans represents a unique count of veterans; veterans were counted only once, even if they received care multiple times during a fiscal year or across the 5-year period. To assess the reliability of the data NEPEC provided us, we discussed with NEPEC officials their methodology and data collection techniques for obtaining and using the data, the data 4 See GAO, VA Health Care: Reporting of Spending and Workload for Mental Health Services Could Be Improved, GAO (Washington, D.C.: May 28, 2010). 5 NEPEC is one of VA s national evaluation centers, and it evaluates and monitors the mental health care delivered by VA nationally. 6 Because providers may document a mental health diagnosis while providing care for a non mental health condition, a portion of this care may be unrelated to a mental health condition. Page 2

7 checks that NEPEC performed, as well as any limitations officials identified in the data. In addition, we did our own review of NEPEC s programming and methodological approaches using data file documentation, code book and file dictionaries, and programming logs NEPEC officials provided. We determined that the data were sufficiently reliable for our purposes. To identify the key barriers that may hinder veterans from accessing mental health care from VA, we searched research databases, such as MEDLINE and PsycINFO, that included peer-reviewed journals to capture relevant literature published on or between January 1, 2006, and March 3, We also reviewed relevant literature that was cited in articles from our original search or recommended to us during the course of our research. To corroborate the barriers we identified in the literature, we interviewed officials from (1) several VA offices the Office of Mental Health Services, the Office of Mental Health Operations, the Office of Rural Health, the Office of Research and Development, and Readjustment Counseling Services; (2) several mental health focused VA research centers the Mental Illness Research, Education and Clinical Center, the Serious Mental Illness Treatment Resource and Evaluation Center, the Center for Chronic Disease Outcomes Research, and the National Center for PTSD; (3) several VA mental health and primary care providers; 7 and (4) a judgmental sample of VSOs. 8 We defined key barriers as those that the majority of VA and VSO officials we interviewed said could have the greatest impact on veterans. As a result, we do not report an exhaustive list of all potential barriers that veterans may face. Finally, to identify the efforts VA has implemented to increase veterans access to VA mental health care, we reviewed documentation and interviewed officials from the same VA offices and mental health focused VA research centers that we interviewed to corroborate the barriers for 7 The mental health and primary care providers we spoke with were identified by VA officials as having specific knowledge of either barriers to veterans accessing mental health care or efforts VA has implemented to increase veterans access to VA mental health care. 8 We spoke with officials from eight VSOs: American Legion, American Veterans, Disabled American Veterans, Paralyzed Veterans of America, Veterans of Modern Warfare, Vietnam Veterans of America, Women Veterans of America, and Wounded Warrior Project. Page 3

8 veterans. We compiled a list of efforts based on those that had been implemented and were national in scope. As a result, we do not report an exhaustive list of all VA efforts. In addition, we did not assess the extent to which VA has fully implemented these efforts or their effectiveness, including the extent to which the efforts eliminate or diminish barriers that may hinder veterans from accessing mental health care. We conducted our work from November 2010 to October 2011 in accordance with all sections of GAO s Quality Assurance Framework that are relevant to our objectives. The framework requires that we plan and perform the engagement to obtain sufficient and appropriate evidence to meet our stated objectives and to discuss any limitations in our work. We believe that the information and data obtained, and the analysis conducted, provide a reasonable basis for any findings and conclusions. See appendix I for a complete description of our scope and methodology. Background VA manages access to services in relation to available resources through a priority system established by law. 9 The order of priorities is generally based on service-connected disability, income, or other special status, such as having been a prisoner of war. 10 Additionally, Congress has stipulated that certain combat veterans discharged from active duty on or after January 2003 are eligible for priority enrollment. VA Mental Health Care VA provides mental health care for conditions such as PTSD, depression, and substance abuse disorders in a variety of facilities, including medical centers, community-based outpatient clinics, and rehabilitation treatment programs. These facilities may include both specialty mental health care settings and other settings. Specialty mental health settings, including mental health clinics, primarily provide mental health services. Other settings may provide mental health services but focus primarily on other types of care, such as primary care. 9 The Veterans Health Care Eligibility Reform Act of 1996, Pub. L. No , 110 Stat. 3177, 3182, 104 (Oct. 9, 1996), codified at 38 U.S.C. 1705, directed VA to establish a patient enrollment system to manage the provision of care and services by establishing priority groups and directing VA to enroll veterans in accordance with the priorities. 10 For example, in fiscal year 2010 approximately 790,000 veterans were identified as having service-connected mental health disorder disabilities. Page 4

9 VA also provides counseling services that focus on mental health issues through its Vet Centers, a nationwide system of community-based centers that VA established separately from other facilities. The counseling services provided by Vet Centers differ from the mental health services provided by other VA facilities in that they focus on counseling to assist combat veterans in readjusting from wartime military service to civilian life but do not diagnose veterans mental health conditions. Veterans needing more acute care for example, veterans with multiple mental health conditions, such as severe PTSD and depression, or those who pose a risk of harm to themselves or others are often referred to VA medical centers for diagnosis and treatment. Veteran Eras of Military Service VA groups veterans by dates or era of their military service based on provisions in federal law. 11 (See table 1.) Table 1: Veteran Eras of Military Service Estimated number of Era of military service Years living veterans, as of September 30, 2011 a World War II Dec. 7, 1941 Dec. 31, million Korea June 27, 1950 Jan. 31, million Vietnam Feb. 28, 1961 May 7, million Persian Gulf War b Aug. 2, 1990 present 3.3 million OEF/OIF b October 2001 present 2.6 million Peacetime Any dates outside of specified eras of service 5.7 million Source: GAO analysis of 38 U.S.C. 101 and VA VetPop2007 data. a Estimates are from VetPop2007, a VA model for estimating the number of living veterans using U.S. Census Bureau and Department of Defense data. There were an estimated 22.2 million total living veterans as of September 30, This total is less than the sum of the number of living veterans from the individual eras of military service because some veterans served in multiple eras. b OEF/OIF is a set of military operations that is considered part of the Persian Gulf War. Although most veterans who have served since 2001 served in OEF/OIF, there are some veterans who served in the Persian Gulf War after 2001 who did not serve in OEF/OIF. For the purposes of this report, we consider OEF/OIF to be an era of military service, and we use the time frame corresponding to the beginning of OEF, the operation with the earliest start date. In addition, we include veterans of Operation New Dawn the name given to combat in Afghanistan after September 2010 in the OEF/OIF era of military service. Finally, for the estimated number of living veterans, veterans who served in both the Persian Gulf War era and the OEF/OIF era are counted in the OEF/OIF era. 11 See 38 U.S.C Page 5

10 VA estimates that as of September 30, 2011, there were approximately 22.2 million living veterans. OEF/OIF veterans represented approximately 12 percent (2.6 million) of that total. More Than 2 Million Unique Veterans Received Mental Health Care from VA over the 5-Year Period from Fiscal Years 2006 through 2010 Over the 5-year period from fiscal years 2006 through 2010, about 2.1 million unique veterans received mental health care from VA. 12 Each year the number of veterans receiving care increased from about 900,000 in fiscal year 2006 to about 1.2 million in fiscal year (See fig. 1.) VA provided this mental health care to veterans in both specialty mental health care and other settings, such as primary care clinics staffed with mental health providers. 13 (See app. II for information on the number of veterans receiving mental health care in specialty mental health care and other settings.) 12 The number of veterans receiving care from VA includes eligible former active duty servicemembers, including Reservists and National Guard members. In some cases, VA also provides care to nonveterans, such as active duty servicemembers or veterans dependents; however, nonveterans were not included in our analysis. Veterans who received care were counted only once, even if they received care multiple times during a fiscal year or across the 5-year period. 13 In fiscal year 2010, about 1 million veterans received mental health care in specialty mental health care settings and about 1.2 million veterans received mental health care in other settings. These numbers do not add to the total number of veterans receiving mental health care in fiscal year 2010 because veterans may have received care in both types of settings. Page 6

11 Figure 1: Number of Veterans Who Received Mental Health Care from VA, Fiscal Years 2006 through 2010 Veterans 2,100, ,060,211 1,800, ,500, ,200, , , ,662 1,027,992 1,118,646 1,203, , , Number of unique veterans, fiscal years 2006 through 2010 OEF/OIF 34,559 (4%) 55,343 (6%) 83,947 (8%) 113,277 (10%) 139,167 (12%) 213,781 (10%) All other veterans 862,570 (96%) 897,319 (94%) 944,045 (92%) 1,005,369 (90%) 1,064,363 (88%) 1,846,430 (90%) Source: GAO analysis of NEPEC data. Notes: The number of veterans represents a unique count of veterans; veterans were counted only once, even if they received care multiple times during a fiscal year or across the 5-year period. We defined mental health care as the care provided to veterans with mental health conditions. A veteran was counted as having a mental health condition if, at any point in the fiscal year, his or her medical record indicated at least two outpatient encounters with any mental health diagnosis (with at least one encounter having a primary mental health diagnosis) or an inpatient stay in which the veteran had any mental health diagnosis. Although the number of veterans receiving mental health care from VA increased for both OEF/OIF veterans and veterans of other eras of service, as shown in figure 1, OEF/OIF veterans accounted for an increasing proportion of the veterans receiving care. Specifically, the proportion of OEF/OIF veterans receiving mental health care from VA out of the total number of veterans receiving mental health care increased from 4 percent in fiscal year 2006 to 12 percent in fiscal year Nonetheless, veterans from earlier eras, such as Vietnam, accounted for approximately 90 percent of the 2.1 million veterans receiving care at VA over the 5-year period from fiscal years 2006 through 2010, although the proportion decreased from 96 percent in fiscal year 2006 to 88 percent in fiscal year VA officials indicated that the increasing proportion of Page 7

12 OEF/OIF veterans receiving mental health care is not unexpected because of the nature of OEF/OIF veterans military service veterans of this era typically had intense and frequent deployments. In addition, according to VA officials, VA has made changes in its mental health screening protocols that may have resulted in more mental health conditions being diagnosed among veterans entering the VA system. For example, VA requires veterans treated in primary care settings to be screened for mental health conditions such as PTSD, depression, substance abuse disorders, as well as a history of military sexual trauma. Additionally, the 2.1 million veterans receiving mental health care from VA accounted for almost a third of the 7.2 million total unique veterans receiving any type of health care from VA over the 5-year period from fiscal years 2006 through Specifically, 38 percent of all OEF/OIF veterans and 28 percent of all other veterans receiving any health care during this time period received mental health care. (See fig. 2.) 14 Among the general U.S. population, an estimated 26 percent of adults experience a mental health condition in a given year. See R.C. Kessler, W.T. Chiu, O. Demler, K.R. Merikangas, and E.E. Walters, Prevalence, Severity, and Comorbidity of 12-Month DSM- IV Disorders in the National Comorbidity Survey Replication, Archives of General Psychiatry, vol. 62, no. 6 (2005). Page 8

13 Figure 2: Percentage of Veterans Receiving Mental Health Care from VA as a Percentage of the Total Number of Veterans Receiving Any Health Care from VA over the 5-Year Period from Fiscal Years 2006 through % of all veterans who received care from VA received mental health care 38% of all OEF/OIF veterans who received care from VA received mental health care 28% of all other veterans who received care from VA received mental health care 2,060,211 veterans received mental health care 213,781 OEF/OIF veterans received mental health care 346,555 OEF/OIF veterans did not receive mental health care 1,846,430 other veterans received mental health care 4,746,552 other veterans did not receive mental health care OEF/OIF veterans not receiving mental health care OEF/OIF veterans receiving mental health care All other veterans not receiving mental health care All other veterans receiving mental health care Source: GAO analysis of NEPEC data. Notes: The number of veterans represents a unique count of veterans; veterans were counted only once, even if they received care multiple times across the 5-year period. We defined mental health care as the care provided to veterans with mental health conditions. A veteran was counted as having a mental health condition if, at any point in the fiscal year, his or her medical record indicated at least two outpatient encounters with any mental health diagnosis (with at least one encounter having a primary mental health diagnosis) or an inpatient stay in which the veteran had any mental health diagnosis. The five most common diagnostic categories for veterans receiving mental health care from VA in fiscal year 2010 were adjustment reaction, depressive disorder, episodic mood disorder, neurotic disorder, and substance abuse disorder. (See table 2.) Within each diagnostic category, there are specific mental health diagnoses; for example, PTSD is one of the diagnoses within the adjustment reaction category. Although veterans of all eras had similar diagnoses, the likelihood of experiencing diagnoses in any one category varied by era. Specifically, almost twice as many OEF/OIF veterans had diagnoses within the adjustment reaction category Page 9

14 compared to the next most common diagnostic category depressive disorder. In comparison, for veterans of all other eras, depressive disorder was the most common diagnostic category, but it was closely followed by adjustment reaction. According to VA officials, the higher relative incidence of adjustment reaction (including PTSD) among OEF/OIF veterans may be due to many factors, including the length and frequency of their deployments and a better understanding of how to identify and diagnose PTSD among mental health care providers. Table 2: Five Most Common Diagnostic Categories for Veterans Receiving Mental Health Care from VA, Fiscal Year 2010 Diagnostic category a Adjustment reaction Depressive disorder Episodic mood disorder Neurotic disorder Substance abuse disorder Description A group of mental health diagnoses, including PTSD, characterized by an emotional and behavioral reaction that develops within 3 months of a life stress, and which is stronger or greater than what would be expected for the type of event that occurred. A group of mental health diagnoses that reflect a sad or irritable mood exceeding normal sadness or grief. A group of mental health diagnoses best recognized by depression or mania that can have potentially severe health consequences. A group of mental health diagnoses characterized by symptoms such as phobias, obsessive thoughts, and compulsive actions, or by losses of specific bodily functions. A group of mental health diagnoses arising from the abuse of alcohol or drugs. Number of OEF/OIF veterans 109,850 (includes 96,916 with PTSD diagnosis) Number of all other veterans 465,448 (includes 383,832 with PTSD diagnosis) Total number of veterans 575,298 (includes 480,748 with PTSD diagnosis) 57, , ,668 38, , ,366 45, , ,814 36, , ,214 Source: GAO analysis of NEPEC data. Notes: Veterans could have more than one diagnosis; therefore the numbers do not add to the 1.2 million veterans receiving mental health care from VA in fiscal year We defined mental health care as the care provided to veterans with mental health conditions. A veteran was counted as having a mental health condition if, at any point in the fiscal year, his or her medical record indicated at least two outpatient encounters with any mental health diagnosis (with at least one encounter having a primary mental health diagnosis) or an inpatient stay in which the veteran had any mental health diagnosis. a Diagnostic categories are based on International Classification of Diseases, Ninth Revision, codes. Page 10

15 Stigma, Lack of Understanding of Mental Health, Logistical Challenges, and Concerns about VA May Hinder Veterans from Accessing Care The key barriers we identified from the literature that may hinder veterans from accessing mental health care from VA, which were corroborated through interviews with VA and VSO officials, are stigma, lack of understanding or awareness of mental health care, logistical challenges to accessing mental health care, and concerns about VA s care. (See table 3 for a description of each of these key barriers.) For example, stigma negative personal or societal beliefs about mental health conditions or mental health care may discourage veterans from accessing care. According to VA and VSO officials we spoke with, some veterans may have concerns that if colleagues or employers find out they are receiving mental health care, their careers will be negatively affected. Table 3: Key Barriers That May Hinder Veterans from Accessing Mental Health Care from VA Key barrier Stigma and beliefs about mental health care Lack of understanding or awareness of mental health care Description Veterans may have: Perceptions that as a result of accessing mental health care they will be viewed negatively by others, such as peers or employers. For example, veterans may feel that by accessing mental health care they will be perceived as weak or having lost control. Confidentiality and privacy concerns. For example, veterans may fear that accessing mental health care would harm their current or future careers. Values and priorities such as family, work, or school commitments that conflict with accessing treatment. Perceptions that treatment may bring up painful or trauma-related feelings and memories they wish to avoid. Perceptions that social networks such as families or military communities have values and priorities that conflict with accessing treatment. Veterans may have: Lack of knowledge about VA s mental health services. Lack of awareness or understanding of their mental health conditions. For example, veterans may have difficulty distinguishing their mental health symptoms from the symptoms they are experiencing as a result of physical injuries. Perception that mental health treatment is only for people with extreme mental health conditions. Veterans may feel that their mental health conditions are not severe enough to warrant treatment or that resources should go to those most in need. Perception that mental health treatment is unnecessary or unhelpful. Page 11

16 Key barrier Logistical challenges to accessing mental health care Concerns about VA s health care Description Veterans may have: Difficulty scheduling appointments. For example, veterans may have challenges coordinating multiple appointments or perceptions that there is limited availability of appointments. Distance and transportation challenges. For example, veterans who live in rural areas may have to travel long distances to obtain treatment. Family challenges, such as arranging child care or spousal support. Other logistical challenges, such as time constraints or physical or mental impairments that may limit the opportunity to obtain treatment. Veterans may have: Perceptions that VA s programs and service options are not adequate to meet their needs, such as not having enough providers or not having enough time during appointments to discuss both health and mental health care needs. Perceptions that VA s services are not uniform across all provider locations (e.g., certain programs are not available at all VA medical centers). Perceptions that VA s services are primarily or only for someone else, such as older veterans, war veterans, male veterans, or veterans with severe disabilities. Perceptions that VA does not provide quality care to veterans, does not treat veterans well, or is not welcoming to particular groups of veterans (e.g., women). Reluctance to talk with a VA mental health provider. For example, veterans may distrust mental health providers or fear that providers will not understand or believe them. Negative perceptions about the government or VA. Source: GAO s review of relevant literature published on or between January 1, 2006, and March 3, 2011, and corroborated by interviews with VA and VSO officials. Many of these barriers are not necessarily unique to veterans accessing mental health care from VA, but may affect anyone accessing mental health care from any provider. According to the Substance Abuse and Mental Health Services Administration s 2008 National Survey on Drug Use and Health, approximately 5 million adults who reported an unmet need for mental health care reported similar barriers. 15 In particular, survey participants cited the following as barriers: a belief that the problem could be handled without care, not knowing where to go for care, and not having the time to go for care. 15 Substance Abuse and Mental Health Services Administration, Office of Applied Studies, Results from the 2008 National Survey on Drug Use and Health, NSDUH Series H-36, HHS Publication No. SMA (Rockville, Md.: September 2009). Page 12

17 Additionally, according to the literature we reviewed and VA and VSO officials we interviewed, some of these key barriers may affect veterans from different demographic groups differently. For example, veterans may be affected by barriers differently based on age, gender, Reservist or National Guard status, or rural location. Age: OEF/OIF veterans, who are generally younger than other veterans, may have concerns about VA s health care system because they perceive that primarily older veterans, such as those who served in Vietnam, go to VA for care. 16 Additionally, some younger veterans may have multiple personal priorities such as family, school, or work commitments that make accessing care a lower priority. Older veterans may have different reasons for not accessing mental health care. For example, stigma and beliefs about mental health care may hinder veterans who served in World War II and Korea from accessing care because they grew up during a time when mental health conditions generally were not recognized and accepted. According to a national survey of veterans, as of March 2010, more than 60 percent of all veterans were 55 years of age or older. 17 Gender: Female veterans may perceive some barriers to accessing mental health care differently than male veterans. 18 For example, some female veterans may not identify themselves as veterans if they did not serve in combat and, as a result, may not access care from VA. In addition, female veterans may have concerns about VA s health care system because they perceive that the care is male oriented, and therefore, VA is not a place where they feel comfortable receiving mental health care. Female veterans are a growing demographic in the veteran population from fiscal year 2010 to fiscal year 2020, the percentage of female veterans in the total veteran population is projected to increase from approximately 8 percent to approximately 10 percent, according to VA s National Center for 16 See for example, M. A. Burnam et al., Mental Health Care for Iraq and Afghanistan War Veterans, Health Affairs, vol. 28, no. 3 (2009). 17 Westat, The National Survey of Veterans, Active Duty Service Members, Demobilized National Guard and Reserve Members, Family Members and Surviving Spouses, prepared for the Department of Veterans Affairs (Rockville, Md.: Oct. 18, 2010). 18 See for example, A. E. Street, D. Vogt, and L. Dutra, A New Generation of Women Veterans: Stressors Faced by Women Deployed to Iraq and Afghanistan, Clinical Psychology Review, vol. 29, no. 8 (2009). Page 13

18 Veterans Analysis and Statistics. 19 (See app. III for data on the gender of veterans receiving care from VA.) Reservist or National Guard status: Reservists and National Guard members may be particularly hindered by privacy and confidentiality concerns because they worry that accessing mental health care might have a negative impact on their military or civilian careers. 20 For example, Reservists and National Guard members may not access mental health care because of concerns about military leaders obtaining access to their VA health records and these leaders treating them differently or limiting their career development because they accessed mental health care. As of November 2010, Reservists and National Guard members made up nearly 50 percent of the OEF/OIF veteran population, according to VA data. Rural location: Veterans who live in rural locations may be particularly hindered by access challenges because of the distance they may have to travel to obtain mental health care. 21 According to the Office of Rural Health, veterans in rural areas are less likely to access mental health services than veterans in urban areas in part because they must travel greater distances to receive care and have more limited public transportation options. According to VA s Office of Rural Health, as of fiscal year 2010, veterans living in rural areas made up 41 percent of the veterans enrolled in VA s health care system. 19 Department of Veterans Affairs, National Center for Veterans Analysis and Statistics, Veteran Population Projections: FY2000 to FY2036 (December 2010). 20 See, for example, C.S. Milliken, J.L. Auchterlonie, and C.W. Hoge, Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning From the Iraq War, JAMA, vol. 298, no. 18 (2007). 21 See, for example, A. West and W.B. Weeks, Physical and Mental Health and Access to Care Among Nonmetropolitan Veterans Health Administration Patients Younger than 65 Years, Journal of Rural Health, vol. 22, no. 1 (2006). Page 14

19 VA Has Implemented Several Efforts to Increase Veterans Access to Mental Health Care VA Has Expanded Options to Increase Veterans Access to Mental Health Care VA has expanded options to increase veterans access to mental health care and implemented education efforts to help connect veterans with care, according to VA officials. VA has begun integrating mental health care into its primary care settings. Specifically, VA now requires its primary care clinics to conduct mental health screenings and has placed mental health care providers in primary care settings. For example, VA requires veterans treated in primary care settings to be screened for PTSD, depression, substance abuse disorders, and history of military sexual trauma. 22 Further, in 2008, VA began requiring primary care clinics that serve more than 1,500 veterans annually to have mental health providers available on-site, able to serve veterans. 23 Historically, veterans were more limited in the ways they could access VA s mental health services. For example, some veterans could receive mental health care only if they went to specialty VA mental health facilities, such as mental health clinics. According to VA, from fiscal years 2008 through 2010, the number of unique patients receiving mental health care in a primary care setting doubled. Several VA officials who work in primary care clinics that have integrated primary and mental health care told us that this integration is critical for lowering the stigma of receiving mental health care and for creating an environment of collaboration among providers for discussing veterans needs and treatment options. VA also has continued to increase the number of its Vet Centers, which provide confidential and free counseling services to address mental health issues. From fiscal year 2008 to August 2011, VA increased the number of Vet Centers from 232 to 292 and, according to VA, plans to 22 Military sexual trauma includes both sexual harassment and sexual assault occurring during a servicemember s military career. VA is required to operate a program to provide counseling and treatment for veterans suffering from sexual trauma under 38 U.S.C. 1720D. 23 Primary care clinics in facilities that serve fewer than 1,500 veterans can provide access to mental health professionals who may not be on-site, through options such as telemental health services. Page 15

20 open another 8 before the end of VA also has expanded the availability of Vet Center services through the use of approximately 70 Mobile Vet Centers specially equipped vehicles that help bring Vet Center counseling services to more veterans, particularly those in rural areas. Vet Centers are often the first point of contact within VA for veterans and, according to VA and VSO officials, can help veterans overcome barriers to accessing mental health care. For example, many Vet Center counselors have firsthand combat experience, which, according to VA, helps them relate to veterans and reduce the stigma of mental health care that veterans may experience. Additionally, VA has expanded its use of call centers to help connect veterans with counseling services. VA call centers are telephone-based systems through which veterans can access free, confidential counseling services. VA officials said that the call centers are an effective way to reach veterans because discussions with call center staff, many of whom are also veterans, may help callers assess whether they could benefit from mental health care. One call center VA operates, the Veterans Crisis Line, allows veterans and their families to call to receive multiple services, including suicide prevention services, 24 hours a day, 7 days a week. 24 According to VA officials, since the Veterans Crisis Line became operational in 2007, it has received more than 400,000 calls and referred approximately 55,000 veterans to local VA suicide prevention coordinators for same-day or next-day services. In addition to the Veterans Crisis Line, VA officials told us that VA has call centers focused on specific populations, such as combat veterans, homeless veterans, and family members of veterans. Moreover, VA has increased its mental health staff from about 14,000 in fiscal year 2006 to more than 21,000 in fiscal year 2011, according to 24 The Veterans Crisis Line ( TALK) was established as a partnership between VA, the Substance Abuse and Mental Health Services Administration, and the National Suicide Prevention Lifeline. Callers to this call center talk to trained counselors about their concerns and can be referred to VA mental health service providers in their area, or receive emergency interventions if necessary. This service is also available to veterans who visit the program s website (http://www.veteranscrisisline.net/) through online chat services. The Veterans Crisis Line is part of VA s Suicide Prevention Program. In addition to the Veterans Crisis Line, VA s Suicide Prevention Program also includes national outreach campaigns to educate the public about suicide prevention and local suicide prevention coordinators who provide information to veterans in their communities. Page 16

21 VA. 25 VA also has expanded the availability of telemental health services, which allow veterans to access mental health care providers remotely through VA medical centers, community-based outpatient clinics, and Mobile Vet Centers. Without telemental health, according to VA, some veterans in rural areas would have to drive as much as 5 hours to the nearest mental health provider, potentially decreasing their access to mental health care. To increase the availability of mental health appointments, as of 2007, VA required its mental health clinics to begin providing after hours treatment times, such as early morning, evening, or Saturday morning treatment times, to better accommodate veterans schedules, including weekday school or work schedules. Additionally, as of 2007, VA has required that all veterans with mental health referrals be contacted within 24 hours to assess their needs; for nonemergency situations, VA requires that veterans receive follow-up care within 14 days of their referral. 26 VA Has Implemented Education Efforts to Help Connect Veterans with Mental Health Care To help connect veterans with mental health care, VA has implemented various efforts to educate veterans, veterans families, health care providers, and other community stakeholders about mental health conditions and care. VA s efforts to help connect veterans with mental health care include collaborations with the Department of Defense, redesigned websites, and other technology-based education tools. VA has collaborated with the Department of Defense to educate veterans and active duty servicemembers returning home from deployments about VA benefits, including mental health care, through activities such as Yellow Ribbon Program events and postdeployment health reassessments According to VA officials, these mental health staff include mental health providers, such as psychiatrists, psychologists, and social workers, as well as additional staff, such as occupational therapists and pharmacists. 26 Also in 2007, VA required its emergency rooms to have mental health staff available for consultation 24 hours a day, 7 days a week, and for its urgent care centers to have mental health providers available during their hours of operation. 27 The Yellow Ribbon Program is a Department of Defense effort to help Reservists and National Guard members and their families connect with local resources, including information on VA mental health care, especially during the reintegration phase that occurs months after servicemembers return home. Postdeployment health reassessments are a Department of Defense program for assessing the physical and mental health condition of servicemembers from 90 to 180 days after deployment. During these events, VA officials are present to help with enrollment in VA health care and to provide referrals, as necessary, for mental health care. Page 17

22 According to VA officials, VA has redesigned some of its key mental health websites including its websites for the Office of Mental Health Services and the National Center for PTSD to raise awareness of and provide convenient access to some of VA s mental health services, such as its call centers and resources for locating mental health providers. VA also has developed interactive technology-based tools to help educate veterans about how to recognize the symptoms of mental health conditions and connect with VA mental health care, including web-based self-help applications, mobile phone applications, and social media sites, such as Twitter and Facebook. In addition, VA has developed tailored efforts to educate specific groups of veterans, such as Native American veterans and veterans with serious mental illness. (See table 4 for examples of VA efforts to educate specific groups of veterans.) Table 4: Examples of VA Efforts to Educate Specific Groups of Veterans about VA Mental Health Care Specific group of veterans Native American veterans Veterans with serious mental illness Homeless veterans Reservists and National Guard members Women veterans Student veterans Description of VA efforts Face-to-face outreach activities, including visits with tribal councils. Trainings for VA staff about how to conduct outreach that is culturally sensitive and focused specifically on the needs of Native American veterans. Program to identify and reengage veterans with serious mental illness, such as schizophrenia, who have discontinued VA treatment. Educational outreach and interventions in community locations, such as shelters and bus stations, to help eligible homeless veterans access VA benefits and care. Regional Stand Down events that provide information and services to homeless veterans, including health screenings that help identify potential mental health conditions and referrals to VA mental health care. VA staff presentations about eligibility for VA benefits, including mental health care, to Reservists and National Guard members at military bases. Outreach to women using websites and brochures describing VA s specialized mental health care for women, such as women-only support groups to help women veterans who have experienced military sexual trauma. a Outreach about VA s mental health services on college and university campuses to veterans enrolled as students. Source: GAO analysis of VA data. a Military sexual trauma includes both sexual harassment and sexual assault occurring during a servicemember s military career. VA also has efforts to educate veterans families about what veterans may be experiencing and how to recognize the possible need for mental health care, according to VA officials. For example, VA has a guide for family members posted on its websites that describes common reactions to being in war, warning signs that a veteran or servicemember might need outside help, and where to go for help. According to VA and VSO officials, veterans families are often the first to notice that the veteran is Page 18

23 having mental health problems and may be more successful in encouraging the veteran to seek care. Additionally, VA has trainings to teach its primary care physicians how to screen veterans for mental health conditions and have discussions with veterans about what to expect during mental health care. VA also has trainings for its providers covering topics such as the assessment and treatment of PTSD or military sexual trauma. According to VA, these types of trainings are important because primary care physicians are often a first point of contact for veterans who might benefit from VA mental health care. Additionally, the trainings help educate mental health care providers about evidence-based mental health practices, including issues regarding gender differences and cultural competencies. For example, according to VA, its National Center for PTSD offers web-based training intended to enhance VA staff sensitivity to, and knowledge of, specific health care needs affecting women veterans. 28 VA also has developed efforts to educate other community stakeholders, including law enforcement personnel, chaplains, and employers, about veterans mental health conditions and VA mental health care. For example, VA has a program that helps law enforcement personnel identify veterans with mental health conditions and connect these veterans to appropriate mental health treatment options. The literature shows that some veterans mental health conditions have been found to increase their likelihood of entering or reentering the criminal justice system. 29 VA also has developed a series of training conferences for chaplains and clergy to educate them to recognize the symptoms of PTSD and other service-related mental health conditions and to refer veterans to VA for care. According to VA, training chaplains and clergy to recognize the symptoms of mental health conditions is important because they are often a first point of contact for veterans in need of assistance. 28 The National Center for PTSD is one of VA s Centers of Excellence, or communities of researchers and educational professionals focused on certain mental health issues. According to VA officials, this center identifies best practices through research, participates in the development of clinical practice guidelines describing best practices, and works to disseminate them through educational programs for VA mental health providers to use, among other activities. 29 For example, see H. Balshem, V. Christensen, A. Tuepker, and D. Kansagara, A Critical Review of the Literature Regarding Homelessness among Veterans, VA-ESP Project # (2011). Page 19

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